Healthcare Provider Details

I. General information

NPI: 1851540272
Provider Name (Legal Business Name): MARYELLEN KEENAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2008
Last Update Date: 09/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 W 12TH ST
NEW YORK NY
10011-8201
US

IV. Provider business mailing address

153 W 12TH ST
NEW YORK NY
10011-8201
US

V. Phone/Fax

Practice location:
  • Phone: 212-604-8177
  • Fax: 212-604-7568
Mailing address:
  • Phone: 212-604-8177
  • Fax: 212-604-7568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number329271
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: